Concierge Medicine: Better Patient Access, But ...

Effects on care quality less certain

A decade ago, when concierge-style practices emerged, "it was primarily for physicians in the second half of their careers, looking to shrink their practices a bit," said James Williams, MD, a physician in Washington, D.C., who recently adopted the model. Today, younger doctors are switching "as a survival technique, a way to fight back against all the changes in primary care, meeting demands for meaningful use and electronic health records," he said.

For himself, he cited issues including rising overhead, stagnant reimbursements, and screw-ups in the call center his conventional practice was using (one patient was inexplicably told that Williams, age 44, couldn't see her because he had retired).

Williams has now joined a trend that a critical American College of Physicians position paper in November called an "innovative practice model ... that is gaining ground." He signed up with SignatureMD, which helps him with marketing and billing, and trimmed his panel from 4,000 patients to fewer than 400.

Patients pay a "membership" fee or retainer of $1,800 a year for "personalized care," or "medicine the way you remember."

"They're paying me to make sure that I'm available when they need me the most, an hour of my time per day for any day of the week," he said. When they call his cell phone, they get a call back the same day, and a home visit if necessary.

Williams and many other doctors interviewed said that these new and widely-varying payment models, increasingly called "DPC" or direct primary care, and which may or may not accept Medicare or private insurance, increase their confidence that they can serve their patients better with less stress on their own lives.

Williams accepts all insurance although he is out of network. Patients pay again for each visit. With income from retainers, he can work on his patients' behalf, for example, arranging a visit with a specialist without requiring a face-to-face visit. He can take his time, not worrying that six patients are waiting to see him next.

Improved access, he said, avoids far more expensive trips to the emergency department or urgent care centers, "and helps them prevent extra trips to the doctor. I've seen firsthand how this type of practice saves Medicare a lot of money."

"Steady, Powerful Uptick"

It's unclear how fast concierge or retainer-based practices are growing.

Estimates quoted in the ACP paper suggest between 1.3% to 9.6% of primary care physicians have converted their entire practices, or are moving toward them with "hybrid" models. Representatives of several concierge management companies and a trade group said the number of physicians in these practices is increasing by 15% or 25% a year.

Regardless of the rate, ACP president Wayne Riley, MD, a clinical professor at Vanderbilt University School of Medicine, called it a "steady and powerful uptick that we can feel, hear, and see."

The big question, Riley said, is whether such care is living up to the promise of its marketing, that it is truly better care. Or whether it may leave many patients who can't afford such fees scrambling to find fewer doctors.

Concierge doctors who advertise they give better care are engaged in "great marketing," Riley said. "But we're an evidence-based organization. We want to see the data that support that contention."

Bret Jorgensen, chairman and CEO of MDVIP, said to be the largest and oldest concierge physician network, said that conversion to these practices actually maintains or expands the number of physicians seeing patients. That's because the models allow doctors to practice long after they might have retired at age 60-65 because they see fewer patients.

"One of our doctors is 80," Jorgensen said.

Frank Ditz, MD, 51, a family doctor in Cocoa Beach, Fla., converted 2 years ago because he felt he was being "pushed to compromise my personal standards, my medical ethics." He was trying to give patients proper medical advice "after seeing them for seven minutes."

"We need to take time, talk with people, find out about their medications, their family and social history ... When you're rushed, and stressed, you can miss the real picture."

Another reason was cost. "Completing a patient's chart in an EHR costs about 5% to 7% of a practice's gross revenue, and you have to jump through hoops that you did these things," He too limited his practice, to 250 patients, and now books appointments for 45 minutes each.

"It's a frightening time now, because today, doctors must be 'economically credentialed,' " he said. "You can be the most caring doctor, and save lots of peoples' lives, but if you're not cost-effective, you're not (accepted) in an insurance plan. The next year, you won't be able to see those patients and you'll lose your house."

No Third-Party Rules

In Los Alamitos, Calif., Marcy Zwelling, MD, said she was "one of the first" to convert her practice to a concierge-style model 10 years ago and now charges her 350 patients a $2,500 annual retainer.

It was a time when "no one could even spell concierge," so she called her practice "Evenings with Marcy."

But back then, "doctors hated me. They thought I was saying I'm better than them. Now, they've lost their professionalism and their autonomy, and they say, 'Shoot. I wish I'd (switched) a long time ago. Can you help me?'

"Every day there's another rule (from insurance or Medicare payers) that doesn't let you do what you need to do for your patients; you have to ask for authorization. You go through 25 hoops to get a patient from point A to point B, or get them the medication they need," she said. "That's been a strong motivator for changing practice models."

Bruce Sachs, MD, a family doctor in Encinitas, Calif., who converted his practice in 2004 to an MDVIP concierge model, said he hears many doctors tell him it's the "alphabet soup" that has become so impossible for them.

Satisfying MU or meaningful use requirements, meeting National Council on Quality Assurance standards for health plans, making sure they submit quality data to the federal PQRS or physician quality reporting system, or meet PCMH, or patient centered medical home requirements "has become onerous, and difficult to achieve. It's harder and harder for physicians to get by, because it's minus 2% here and 5% there."

"They say, I feel like I'm just doing paperwork and not much else."

But Sachs isn't about to tell colleagues life is easier. "It's more gratifying, because physicians are practicing medicine, but we're still working very, very hard," he said.

Immoral and Unethical?

Concierge practices are not without their strong critics.

Paul Speckart, MD, a former ACP regent who is in a five-physician San Diego practice, called it "immoral and unethical," with no proof that concierge practices are good for society at large.

"I decry the compartmentalization of patients according to 'who can pay' and 'who can't pay,'" he said. "It's antithetical to democracy. Look at it this way. What would happen if we all went into concierge medicine? Where will other patients get care? The emergency room?"

In fact, he said, these models are nothing more than a "physician cop-out; it makes life easier for the physician, but it's not what's best for patients. I've seen a lot of people who say they're moving to these models 'to devote more time for their families,' and yet they have no families. They just don't want to work that much."

"We're all frustrated" by the increasing demands on primary care doctors, he acknowledged. "But the answer is not to convert to a concierge practice. The answer is, you have to roll up your sleeves and go to work."

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